Considerations for School Nurses: Health Equity Implications During COVID-19 Pandemic
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Considerations for School Nurses: Health Equity Implications During
COVID-19 Pandemic
Disclaimer
This document provides a summary of currently available resources that school nurses can
consult as they formulate independent nursing judgement for their practice or when
participating in policy discussions in their districts. This document is not intended to provide
clinical standards or guidelines. The school nurse is responsible for complying with applicable
federal, state, and local laws, regulations, ordinances, executive orders, policies, and any other
applicable sources of authority, including any applicable standards of practice. Published
January 1, 2021.
Introduction
Children of racial or ethnic subgroups are disproportionately affected by COVID-19 and chronic
diseases, such as asthma, diabetes, obesity, and mental health issues (Centers for Disease
Control and Prevention [CDC], 2020, Leeb et al., 2020, National Center for Health Statistics,
2019). In the United States, 25% of children and adolescents have chronic health conditions,
7.5% have unmet health care needs, and 5% have multiple chronic conditions (Miller et al.,
2016). School-aged children with a documented health condition, of Hispanic ethnicity or Black
race have been more likely admitted to a hospital or intensive care unit than their White peers
suffering from COVID-19 infection during the COVID-19 pandemic (Leeb et al., 2020). The
presence of a chronic illness and potential long-term effects from COVID-19 may interfere with
education, relationships, health and significantly affect future life outcomes.
Health Equity
The Robert Wood Johnson Foundation (RWJF) defines health equity as “everyone has a fair and
just opportunity to be as healthy as possible” (Braveman et al., 2017, p. 2). Health equity is a
moral and human rights principle focused on reducing and eliminating health disparities
(Braveman et al., 2017). When obstacles, such as poverty, racial discrimination, powerlessness
resulting in lack of access to health care, excellent education, quality jobs with a sustainable
income, housing, and a safe environment, are removed, equity is obtained (Braveman et al.,
2017). Equity allows people a reasonable and nondiscriminatory opportunity to attain
healthiness (Braveman et al., 2017). School nurses can work towards health equity within their
community by identifying racial discrimination and disparities that affect students' health and
education, especially during the COVID-19 pandemic.
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Published 1/4/2021, Revised 1/26/2021Chronic Disease
Asthma
Black, Hispanic, multiple-race non-Hispanic, Indigenous children, and children in lower
socioeconomic status disproportionally share the burden of asthma. Asthma is more prevalent
in children than in adults. In 2018, over 5.5 million, or 7.5%, children were diagnosed with
asthma nationally (CDC, 2020). Nationally, non-Hispanic Black, Puerto Rican, multiple race non-
Hispanic, and American Indian or Alaskan Native children have a higher prevalence of asthma -
14.2%, 13.6%, 13.0%, and 10.2%, respectively compared to their White counterparts (6.8%) in
2018 (CDC, 2020). Healthcare utilization for children with asthma, as seen in emergency
department visits and hospitalization rates, is 2.6 times higher for Black children than White
children (CDC, 2018).
Racial and socioeconomic neighborhood stratification due to current and historic structural
processes, such as systemic racism and housing laws, has contributed to asthma disparities
(Kranjac et al., 2017). Black children living in low socioeconomic neighborhoods have higher
rates of asthma morbidity compared with White children. The causes of this disparity include
inadequate access to medical treatment, exposure to higher levels of indoor/outdoor allergens
in their environments related to housing conditions, and greater levels of ambient air pollutants
(i.e., O3, PM2.5) (Kranjac et al., 2017; Loftus & Wise, 2016). Poor conditions commonly found in
low-income housing, such as over-crowding, water damage, pest infestation, mold, and chipped
paint, can trigger asthma exacerbations. (Kranjac et al., 2017). Additionally, children who live in
high violence neighborhoods are susceptible to higher exposure to indoor air pollutants due to
prolonged periods spent indoors (Kranjac et al., 2017)
Obesity
Black and Hispanic children are more likely to be overweight, obese, or have obesity-related
diseases than non-Hispanic White children (Ryabov, 2018; Sharifi et al., 2016). The prevalence
of childhood obesity in 2016 was 18.5% (CDC, 2019). Childhood obesity is a moderate predictor
of adult chronic health conditions and disease: 31% of adulthood diabetes, 22% of
hypertension, and 20% of adult cancers occurred in individuals who were categorized as obese
or overweight in childhood (Llewellyn et al., 2016). Hispanic boys and Black girls have the
highest prevalence rates of childhood obesity and the highest mean body mass index (BMI)
scores (Min et al., 2018). There is a correlation between high pediatric BMI levels and low
family income, household socioeconomic status, and education level (Min et al., 2018; Ryabov,
2018). Decreased opportunities for physical activity and increased availability of high-fat foods
influence the occurrence of childhood sedentary or fast-food lifestyle (Min et al., 2018; Ryabov,
2018). Children of single-parents or those in large households have an increased risk of
consuming prepared food items that are high in fat and sodium that contribute to a higher BMI
score (Ryabov, 2018).
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Published 1/4/2021, Revised 1/26/2021Children in low and middle-income groups have higher prevalence rates of obesity, 18.9% and
19.9%, respectively, compared with children in high-income groups, 10.9% (CDC, 2019).
Hispanic and non-Hispanic White children who grow up in higher socioeconomic status homes
and with at least one college-educated parent have a lower risk for obesity (Fradkin et al.,
2015). However, there is no association between socioeconomic status and obesity in Black
children (Fradkin et al., 2015). There is an inverse correlation between socioeconomic status
and obesity in White children (Wang, 2011). The built environment contributes to obesity
disparities, but not as much as the socioeconomic status of the neighborhood (Sharifi et al.,
2016). However, these do not entirely explain racial and ethnic childhood obesity disparities
(Sharifi et al., 2016).
Diabetes
There are racial/ethnic disparities surrounding children with type 1 (TID) and type 2 (T2D)
diabetes (Divers et al., 2020). Between 2002 and 2015, there was a steeper increase in the
number of TID among Black, Hispanic, Asian and Pacific Islander children than White children
(Divers et al., 2020). Additionally, there are racial and ethnic disparities in incidence rates of
children with T2D; American Indians (3.69), Black (5.97), and Hispanic (6.45) children have the
highest incidence, compared with White children (0.77/100,000) who have the lowest
incidence of T2D (Divers et al., 2020).
Although T1D incidence are highest among White children and adolescents, Black children
experience higher mortality rates (Saydah et al., 2017). Between 2012 and 2014, Black children
had the highest mortality rate from diabetes than White and Hispanic children; Black children's
death rate was 2.22 times White children's death rate, and 3.36 times Hispanic children's death
rates (Saydah et al., 2017). These disparities may be due to differences in healthcare access and
services, diabetes self-and parent-management education, and overall diabetic care (Saydah et
al., 2017). Black children with T1D have higher mean hemoglobin A1c and more often
experience diabetic ketoacidosis and severe hypoglycemia than White and Hispanic children
(Willi et al., 2015).
Racial and ethnic disparities in insulin treatment methods and outcomes exist in children with
T1D after adjusting for socioeconomic status. For example, White children use insulin pumps
more frequently than Black or Hispanic children (Willi et al., 2015). Black and Hispanic children
with T2D experience inadequate glycemic control more often than White children (Butler, 2017;
Rothman et al., 2008). Low caregiver educational attainment, high levels of stress, and low
socioeconomic status contribute to poor glycemic control in children with T2D and can create
adverse psychosocial outcomes (Butler, 2017). Black children with T2D experience lower quality
of life due to the disease than White children. Also, Hispanic parents/guardians have a higher
caregiver burden due to disease management (Butler, 2017).
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Published 1/4/2021, Revised 1/26/2021Mental Health and Trauma
Children in racial and ethnic subgroups disproportionately experience exposure to poverty,
food insecurity, violence, neighborhood disorganization, repeated experiences of
discrimination, and chronic exposure to racism, which are risk factors for poor mental health
(Alegria et al., 2010). Increased isolation and poverty rates are correlated with an increased risk
of developing adjustment difficulties, depression, behavior problems, anxiety, and related
disorders, such as posttraumatic stress disorder [PTSD] (Alegria et al., 2010). Those with
mental-health illness in childhood, such as PTSD, anxiety, aggressive behavior, and depression,
experience an increased risk of developing physical and mental health problems in adulthood,
ultimately impacting health and academic achievement (Abrams et al., 2020; Larson et al.,
2017).
Children in racial and ethnic subgroups, children living in single-parent households, children
whose caregivers have low education levels, and those living in poverty are at a greater risk of
experiencing exposure to trauma (Larson et al., 2017). Chronic exposure to trauma increases
the risk of developing mental health disorders, school problems, emotional and behavioral
difficulties, substance use, and sexually risky behavior and negatively impacts future
educational and social advancement and employment (Larson et al., 2017). There is an inverse
correlation between community violence and performance and engagement in school, with a
higher school dropout rate in children exposed to chronic traumas (Larson et al., 2017)
Non-Hispanic Black and Hispanic youth and those with low socioeconomic status
disproportionately lack access to mental health treatments and mental healthcare providers, as
evidenced by lower medical expenditures and mental health service utilization compared to
affluent, White children (Abrams et al., 2020; Hodgkinson et al., 2017; Larson et al., 2017).
Non-Hispanic Black children have the highest rates of mental-health-related emergency
department visits (Abrams et al., 2020). The rates of mental health-related emergency
department visits are more rapidly increasing for Hispanic children than non-Hispanic White
children (Abrams et al., 2020). White children use outpatient mental health services more than
Black and Latino children (Larson et al., 2017).
Children of lower socioeconomic status have higher rates of unmet mental health needs and
mental health problems than children of higher socioeconomic status (Hodgkinson et al., 2017).
Low-income minority children are less likely than their White counterparts to access mental
health care treatment (Larson et al., 2017). Families receiving public insurance was a predictor
of less access to mental health care treatment (Larson et al., 2017). Children with public
insurance are more likely than children with private insurance to have a gap in mental health
insurance coverage (Larson et al., 2017). Additionally, children in low socioeconomic standing
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Published 1/4/2021, Revised 1/26/2021have a worse posttraumatic response because their low-resource environment impedes their
ability to recover from traumatic experiences and increases the likelihood of future mental
health impairments (Andrews et al., 2015).
Area of residence also impacts access to mental health treatment. White children are more
likely to receive mental health treatment in urban areas than Black children and Latino children
(Hodgkinson et al., 2017). However, White children in rural areas are less likely to receive
mental health care than White children in urban areas (Hodgkinson et al., 2017). There are no
racial or ethnic disparities for students receiving mental health treatment in school (Larsen et
al., 2017). However, rural Black students had higher participation rates in school-based mental
health screening programs than White adolescents (Larson et al., 2017).
School Nurses Can Address Inequities
It is school nurses' moral and ethical duty to address inequities that surround health and
education. A school nurse must critically assess the social determinants of health that affect
students' health and well-being (American Nurses Association [ANA] & National Association of
School Nurses [NASN], 2017). According to the Standards of School Nursing Practice, Standard
7, the school nurse must protect human rights, promote health diplomacy, enhance cultural
sensitivity, and reducing health disparities through a school-wide approach to identify and
dismantle inequities within the education setting (ANA & NASN, 2017). Furthermore, the school
nurse can address inequities by encompassing Standard 8, culturally congruent practice, and
Standard 16, utilizing "appropriate resources to plan, provide, and sustain evidence-based
nursing practices that are safe, effective, and fiscally responsible" (ANA & NASN, 2017, p. 80).
Health equity is a practice component of the Community/Public Health principle in the
Framework for the 21st Century School Nursing PracticeTM (Framework) (NASN, 2016; 2020). In
addition, all the principles of the Framework (i.e., Care Coordination, Leadership, Quality
Improvement, Community/Public health, and Standards of Practice) encompass skills that
school nurses use daily to help students be healthy, safe, and ready to learn (NASN, 2016). In
achieving health equity, school nurses may use community/public health skills, including
connecting students and their families to resources that address rent assistance,
unemployment benefits, or food access. Additionally, school nurses should provide information
to eligible children's families or guardians to enroll them in healthcare coverage by Medicaid or
the Children’s Health Insurance Program (CHIP). The school nurse embodies the principle of
Leadership by becoming an influential member of a school system or state-level
interdisciplinary advocacy team that addresses systemic racism and critically evaluates, creates,
and edits policies to reduce disparities and provide resources that promote equity. The school
nurse collects data on the number of case management supports provided for students which
meet the Quality Improvement principle implementation. The principle of Standards of Practice
is the guiding principle for the school nurse decisions and actions in the provision of school
5
Published 1/4/2021, Revised 1/26/2021nursing services using clinical guidelines, evidenced-based practice, and critical thinking to
problem solve identified social needs and racial inequities. Finally, the school nurse uses the
principle of Care Coordination to encourage the inclusion of a culturally competent, evidence-
based curriculum that assists in recognizing implicit bias and addresses racism (NASN, 2016;
2020a; 2020b; National Association of State School Nurse Consultants, 2020).
The COVID-19 Pandemic
The Annie E. Casey Foundation reported from mid-September to mid-October 2020, families
with children in their homes had serious issues during the pandemic. Racial and ethnic
subgroups were adversely impacted. 23% of Black families and 19% of Latino families expressed
sometimes or often not having enough food to eat, compared to 10% of White families. In
addressing the possibility of losing their homes, 36% of Black families, 39% of Hispanic families,
and 30% of White families reported that they were likely to be evicted or foreclosed on (2020).
The majority of those experiencing issues are concentrated among Black and Latino
households, households with annual incomes below $100,000, and households experiencing
job or wage losses since the start of the outbreak (RWJF, 2020). The COVID-19 pandemic has
amplified health disparities that are apparent among vulnerable communities. Students, their
families, and school staff within these communities may experience unequal access to testing,
treatment, and preventive measures and be at an increased risk for illness due to pressures to
continue working in unsafe conditions.
School Nurse Health Equity Assessment and Resources
School nurses can assist students and families during the COVID-19 pandemic and return-to-
school by assessing family social needs by asking the following questions to identify obstacles to
health equity and provide resources to remove identified obstacles. It is essential that school
nurses establish a trusted, confidential interaction with students and families when conducting
this assessment and are sensitive to the questions and responses that are exchanged.
Assessment questions include:
• HEALTH INSURANCE COVERAGE - Does your child have health insurance?
o If the student is not insured, offer state and local resources for Medicaid or other
insurance enrollment.
o Resources include:
▪ Coverage resource - go here
▪ State programs go - here or call 1-877-KIDS-NOW (1-877-543-7669)
▪ School-based outreach and enrollment toolkit - go here
▪ Identify county and state contacts for enrollment and set up an appointment
▪ Or refer to local insurance coverage experts
o Identify if the school has staff to enroll families in Medicaid, SNAP, or other
programs
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Published 1/4/2021, Revised 1/26/2021o If the student has a high deductible health insurance plan, families may not have
financial resources for out-of-pocket costs for sick visits or prescriptions. See section
Access to Healthcare.
• HOUSING – Do you currently have secure housing?
o Connect with local resources to assist in housing
o Public schools have access to McKinney-Vento funds to help families secure
temporary housing
• HOUSING - Can you afford to pay rent/mortgage?
o Connect with local resources to assist in housing
• EMPLOYMENT STATUS – Are you or family breadwinner currently employed?
o If not employed, ask if they have applied for unemployment assistance
o Resources include:
▪ Provide a list of local family advocates that can help get health coverage or
benefits due to unemployment.
▪ Information regarding unemployment benefits under the CARES act - go here
▪ Health coverage options for the unemployed - go here
▪ Medicaid and CHIP information – go here
• FINANCIAL STATUS – Are you having difficulty paying your bills? Which bills do you need
help with paying?
o Information regarding bill assistance - go here
• FOOD SECURITY - Do you have access to enough food for the family? Do you ever worry
about how to make your food supply last longer? Does your student receive food at school?
o Provide food access resources in the community, including food pantries, charitable
food delivery organizations, and SNAP/WIC.
o Help applying for free or reduced meals at school
o Resources include:
▪ SNAP
▪ WIC
▪ Free and Reduced-Price School Meals
▪ Food distribution programs
▪ Food and Nutrition Services (FNS) programs
▪ Child Nutrition Programs
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Published 1/4/2021, Revised 1/26/2021• ACCESS TO HEALTH CARE - When was your student's last well-child or health care visit?
o Review student’s immunization status
o Review student’s prescription drug status
o Provide resources for providers at federally qualified health centers or community
providers accepting uninsured or under insured children
o Provide information on Vaccines for Children programs in your community
o Provide resources for prescription drugs if uninsured and not eligible for Medicaid.
▪ https://www.americaspharmacy.com/howitworks
▪ Provide suggestions for local pharmacies, such as Walmart, CVS, Walgreens,
and others that provide generic discounted prescriptions
• ACCESS TO HEALTH CARE - Do you have a vehicle or access to transportation to get to
medical appointments or COVID-19 testing sites?
o If the family has Medicaid, the cost of transportation to medical appointments is
covered
Questions Specific to the COVID-19 Pandemic
• PERSONAL PROTECTIVE EQUIPMENT - Do you have the personal protective equipment you
need, such as cloth masks for your student, yourself, hand soap, cleaning products, hand
sanitizer?
o Provide school or community resources to provide masks/PPE, cleaning products,
and hygiene products to children and families such as PTA’s or faith-based
organizations.
• COVID-19 RISK - Has anyone in your household contracted COVID-19? Been in close contact
with any person who may be sick with COVID-19? Travel to areas where COVID-19 is high?
Been around anyone who has traveled from another state or country?
o Connect families with local public health.
• COVID-19 EXPOSURE PLAN - What is your plan for you and your family if exposed to COVID-
19? Can you and your family isolate for 7-14 days? What is your plan for working, income,
and/or food access?
o Provide a list of locations within your community that provide COVID-19 testing
o Provide phone number of the local health department that does contact tracing if
exposed
• EDUCATION RESOURCE – INTERNET OR WI/FI ACCESS - Do you have access to reliable
internet and/or Wi-Fi at home? Is your school/community providing hot spots or technical
support to families?
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Published 1/4/2021, Revised 1/26/2021o Provide community-based organizations providing free public Wi-Fi
o Assistance for lowering the cost of the internet - go here
• EDUCATION RESOURCE – TABLET ACCESS - Do you have a tablet for remote based learning
for your student? Do you have enough tablets? Is your school or community providing
tablets, such as chrome books or lap top computer, to families?
o Provide local community or school-based resources for tablets, chrome books, or
laptops
• WORK/SCHOOL BALANCE - Are you currently working out of the home during school hours?
Will you be home if the student is home doing remote learning? Will the student be alone
during the day? Can you help your student(s) with schooling, and do you feel confident
assisting the student?
o Provide community childcare resources such as Boys & Girls Club and faith-based
organizations
• MENTAL HEALTH - How are things going at home? How do you feel about the relationships
in your life? How does your partner treat you? Are you and your children safe in your
current living situation?
o Domestic abuse, addiction issues, incarceration, or other social needs may arise
during this time.
o Connect with school/community support or mental health services if there was an
exposure/illness/death related to COVID-19
o Additional resources for students, families (and school staff) include:
▪ COVID-19 Resources to Prevent Child Abuse
▪ School Mental Health Resources for COVID-19
▪ COVID-19 resources for k-12 schools from the CDC
▪ Talking to Children About COVID-19
▪ Trauma-Informed School Strategies Due to COVID-19
▪ Coping in Hard Times: Fact Sheet for School Staff
▪ National Domestic Violence information – go here
▪ Substance Abuse and Mental Health Services Administration - go here
o School nurses are mandatory reporters of child abuse and neglect. Further
information may be found here and state statutes here
• CLOSING - Are there any other concerns or needs that you need assistance with?
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Published 1/4/2021, Revised 1/26/2021Additional Equity and Racism Resources
o Tools to Raise an Anti-racist Generation
o Diverse children's books
o Anti-racist Reading List
o Preventing Racial Inequity in Schools and Beyond
o Talking About Race
o Talking Race With Young Children
o Talking to Children About Race
o Implicit Bias Resource Guide
Acknowledgment of Author:
Kaitlyn Kodzis, BSN, RN
Masters Candidate (December 2020), Community Public Health Nursing
University of Maryland School of Nursing
10
Published 1/4/2021, Revised 1/26/2021References
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https://doi.org/10.1542/peds.2014-1774
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